Friday, August 18, 2017

Compliance Isn’t Easy

Being Deliberate

If your EMS agency is going to strive to be 100% compliant with all of the rules and regulations that we all have to navigate in the EMS billing arena, then it means that your organizational culture must be deliberate.

Compliance isn’t easy.

Compliance Isn’t Easy
The problem with what we have just written is the busy EMS world that we all operate in every day, sometimes does not allow for difficult. Time to think and do becomes just do and worry about it later.

That’s where we have gotten into trouble in the past.

Margins are tight…

Because every EMS agency’s operating margins are tight, we tend to get into a mindset that seems to justify cutting a corner here and there because we feel we are entitled to be reimbursed by whatever means.

We can all become very lofty in our heads… “They owe us this money because they underpay us anyway.” This leads us to believe that we have some kind of righteous moral high ground and can look the other way if we are reimbursed by cutting corners and looking the other way when compliance rules are cheated.

Not so!

Rules are Rules

The rules are the rules. In this greatest nation on earth, whether you agree with the politics on Capitol Hill or not, if Congress or a State Legislature superimposes a requirement on us then it is what it is and we must comply.

It may not be easy to record odometer readings to the nearest tenth of a mile, but we all have to do it.

It seems trivial that a healthcare professional cannot just sign a Physicians Certification Statement with the same scribble the doctor uses on his/her prescription pad and must print his/her name, credentials and date the signature too. Plus it really seems unfair that we have to chase after that same doctor when he/she doesn’t follow the rules.

But we have no choice.

The Penalties are Stiff

No longer do we operate in a culture that we can just make up for it on the back end. Failing to comply with the rules today can result not only with the requirement to pay back the money that should never have been paid in the first place, but it may also result in civil and/or criminal penalties depending on the severity of the infraction.

The penalties are really stiff and the elected officials give more power to the bureaucrats every day. Routine audits are commonplace. Recovery activity is at an all-time high.

Navigating the Waters

So to navigate the waters, your EMS agency must work hard and continuously to foster a culture of compliance. We offer these steps to begin and succeed at the process…
  1. Focus on excellent documentation- we preach this continuously in this blog space and we are laser focused on educating our clients within our billing office culture. There must be continual dialogue and education with the people that are crewing your ambulances regarding the effectiveness of their documentation in the Patient Care Report (PCR) which is the direct link between the street and the billing office. Your billing office must be an equal watchdog over the process and by the same respect, someone should be diligently watching over your billing office.
  2. Ask questions- EMS agency administrators must constantly be asking questions about the process in order to determine if any coloring is falling outside of the lines. If you, as an administrator, don’t feel qualified to do a systems review on the billing process- and we mean from street to office to payer, then bring an objective someone in to review the process. Likewise, be certain if you are outsourcing your billing to a third-party that you can constantly monitoring the flow of information. Be sure that your billing contractor has a keen understanding of all of the rules and regulations.
  3. Build compliance training into your routine- the staff on the street and in your billing office won’t just osmose the rules and regulations nor will they know how to apply them without training. Are all of your billers (in-house or outsources) Certified Ambulance Coders? Do you regularly work compliance-focused training into your staff meetings?

Unless the edict to be compliance fanatical comes from the top down, your EMS agency will be open for a slip. That slip could become very costly, embarrassing and maybe even fatal.

Run! Now! Begin today!

Dust off that compliance plan binder on the shelf and make it work!

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about how Enhanced can benefit your EMS agency, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.

Friday, August 11, 2017

Railroad Medicare Cites 32.6% Denial Rate in Widespread Review

Here we go again…

The Railroad Medicare program, administered by government contractor Palmetto Government Benefits Administrators (Palmetto GBA) has published the results of their latest “widespread review” of BLS Non-Emergency Transports.

Here we go again…

Railroad Medicare Cites 32.6% Denial Rate in Widespread Review
Continually, our industry is turning in dismal audit results with this contractor which is why continuously they conduct these reviews. Of 4,985 claims reviewed with HCPCS procedure code A0428, 1,623 claims were denied equating to a denial rate by dollars of 32.6%.

When are we going to get it?

Inexcusable!

The fact that there were 650 no response scenarios is downright inexcusable! That’s a cool 40% of the denials issued within the review.

Wow!

Do we in the ambulance industry expect to remove ourselves from the CMS microscope if we can’t even take the time to respond with the records requested when summoned to participate in these reviews?

Responding is NOT optional. It’s not whether or not we feel like responding to the requesting contractor and by not doing so we will keep this blasted target on our backs for the foreseeable future.

When the request for records shows up in your mailbox, your billing office and your administration best be running around the office to pull those records and ship them out to the Medicare entity requesting them.

Are you kidding me?

Another 40% of the denials were attributed to insufficient documentation.

Are you kidding me?

Its 2017 people! Modern EMS has evolved so far in scope of practice and lifesaving technology and ability and yet we document like it’s 1967 and there is an abundance of Medicare dollars. No one cared in 1967 whether we billed for services or not and if we did we were but a small subsection of the Medicare payments that were issued.

Not so today.

In order to be reimbursed by Medicare and keep the money while surviving the audit trend unscathed your EMS agency MUST teach strict compliance and it must be a cultural thing to demand truthful, concise and complete run documentation.

A well-written Patient Care Report isn’t an option it’s a requirement.

The Railroad Medicare contractor cited these insufficiencies as being the most prevalent…
  • PCR incomplete/omitted
  • Wrong Date of Service/Wrong Patient
  • Documentation illegible (ever hear of ePCR programs? Huh?)
  • Lacked sufficient documentation to support medical necessity (like running nails over a chalkboard to us…grrrr….)
  • If required, a Physicians Certification Statement was omitted for the response to the request for review or it was incomplete.

The Importance of Signatures

Out of 1,623 denials, 130 of them were denied for a “non-confirming” signature scenario. Palmetto GBA listed the various types of in inadequacies…
  • Physician Certification Statements (PCSs) for repetitive non-emergency transports were not signed by an M.D. or D.O.
  • PCS not signed prior to a repetitive transport scenario
  • Transport was more than 60-days from the PCS signing
  • Illegible signatures with no printed ID of the signaturee
  • No credentials listed and/or an inappropriate person signed the PCS
  • Beneficiary/patient signature either was missing and/or not dated
  • When the patient was unable to sign, no representative signed in the patient’s place

Our billing office has preached the signature sermon over and over so much that we know our clients probably get tired of hearing from us. But, this review is proof positive that we cannot mess around with the requirement.

60 more…

Finally, 60 more claims were denied when Railroad Medicare’s review staff determined the trip was not reasonable or necessary.

We must inquire….where are all of your call intake staff members? Are they sleeping? Are they playing video games? Well they must be, because to take an unreasonable or non-Medically Necessary run in today’s environment is not making good use of anyone within your organization’s time or energy.

Be smart when doing call intake. Develop consistent questions you need to ask when the phone rings and someone is on the other end with a transport request.

Just because the wheels on the woo-woo bus are turning doesn’t mean that the cash will be flowing if we don’t do things right.

And…until we get it right….Railroad Medicare will conduct yet another review over the next 3 months?

So get it right!

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about how Enhanced can benefit your EMS agency, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.

Friday, August 4, 2017

Properly Executing the Medicare ABN-Part II

Just about one year ago, we used this blog space to publish a two-part series on how to properly execute the Medicare ABN. With the release of this new form, we think it is important to loop back and re-post the series once again this year since there will be renewed interest in reviewing the subtle changes that have been made to the form. Following last week's post, we present the conclusion to this series.…



Last Week

Thanks for returning to read out two-part series, Properly Executing the Medicare ABN. 

Last week we introduced the Advance Beneficiary Notice of Noncoverage (ABN) to you and explained the theory behind the use of this government- issued form.

Properly Executing the Medicare ABN-Part II
You’ll recall that we explained that the ABN is never used in a 9-1-1/emergency setting and described how the actual mandatory use of the form is limited to those incidents when the patient could receive services at the sending facility but is being transported to a second facility anyway.

Plus we outlined the optional uses for the form.

What you can do…

This week we’ll describe the proper execution of the form in the field.
First let’s tackle what you, as a representative of your EMS agency, can do.

The form can be modified to include your EMS agency’s Legal Business Name, Address and your phone and fax numbers.

You may have the form pre-printed professionally, or simply make advance copies. Many EMS agencies have the form printed in a format that allows a copy to be presented to the patient, while keeping the original with signature following the transport, such as an NCR form.

You may add the patient’s name and his/her Medicare beneficiary number prior to presenting the form.

The middle section, the text box that lists the Services to be provided, the reasons why Medicare may not pay and the Estimate Cost can be modified to fit your particular anticipated needs for use in informing the patient of his/her options.

Prior to presentation, at least one service option should be checked off and chosen for notification to the patient and an estimated cost must be added to the form in the appropriate blank corresponding to the service to be provided that is deemed to be uncovered by Medicare.

What you cannot do…

First, you cannot alter the basic layout or the font size of the form. Because this form is published by the Federal Government and approved by the Office of Management and Budget (OMB) and the Centers for Medicare and Medicaid Services (CMS), it cannot be majorly altered in any way.

The presentation and execution of the form should not be made in the ambulance. Once the patient is loaded into the ambulance vehicle, most patients would feel obligated to sign and continue with the transport. You must present the ABN prior to patient loading which affords the patient the ability to refuse the transport or seek another EMS agency to move the patient, based primarily on the estimated out-of-pocket cost the patient will incur.

You and your EMS agency’s providers are not permitted to fill any information out below the notification text box. The patient must independently choose one of the three options they have for billing and/or presentation to the Medicare payer without your assistance.

Finally, neither you nor anyone else associated with your EMS agency is permitted to sign the form. Only the patient or a patient representative can sign and once signed the signature, if not legible, should have a printed name below or near the signature and the signature must be dated (specifically dated next to the actual signature.)

If a representative signs the ABN, then be sure to print the word “representative” next to that person’s signature.

Estimate Cost- Good Faith Effort

When providing the mandatory estimated cost on the form, the rules state that you must provide an estimated cost that should be within $100 or 25% of the actual cost of the transport- whichever is greater.

You may provide an estimate that exceeds the actual cost in which case the beneficiary would not be wrongly misled and impacted financially as opposed to when the estimated cost of the transport is represented to be substantially lower than the eventual billed-to-patient amount.

Person signing must be responsible party…

Unlike the signature authorization forms, not just anyone can sign the ABN.

Because this form is ultimately a financial decision form, it is extremely important that the patient or a legally/financially responsible person sign the form. Signing the form represents that the patient or appropriate patient representative signer (such as a spouse, Power of Attorney, guardian, etc.) is legally authorized to accept ultimate financial responsibility for the billed costs of the transport.

Once signed, it is recommended that you retain the ABN with the original signature on behalf of your EMS agency, while the patient should be presented with a copy for his/her records. Once fully executed, no changes or alterations should be made to the ABN by anyone in your EMS agency.

The Ambulance Billing Services blog is brought to you as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS third-party billing contractor serving Fire/EMS agencies across the United States. To learn more about who we are and what we do, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.

Friday, July 28, 2017

UPDATE-Properly Executing the Medicare ABN-Part I

Misunderstood

The Centers for Medicare and Medicaid Services (CMS) has just announced the release of the revised Advance Beneficiary Notice of Noncoverage (ABN). It is important that those of us in the ambulance world who use this form on a regular basis begin to use this version immediately.

Properly Executing the Medicare ABN-Part IJust about one year ago, we used this blog space to publish a two-part series on how to properly execute the Medicare ABN. With the release of this new form, we think it is important to loop back and re-post the series once again this year since there will be renewed interest in reviewing the subtle changes that have been made to the form.

We find that EMS administrators and providers alike are often confused about when and how to use this form. This week we’ll take a look at the form itself, its origins and the theory behind the execution of the form, specifically when and when not to use a Medicare ABN. 
Then next week we’ll explore the actual presentation of the ABN to patients in the field.

What is it?

The form is officially the CMS-R-131 (Exp. 03/2020) form which carries the Office of Management and Budget approval number 0938-0566.

So what, you say?

Well, there is importance in those numbers. Namely, it’s the only form used in the field that is mandated to be used as released by the Federal Government. There are specific rules that surround how it can be presented, right down to the font size and specific wording, but especially how it is to be filled out and executed.

The form must be used when mandated and no other “waiver” form is acceptable for a Medicare beneficiary.

When not to use…

Before we begin the discussion about the ABN’s use, let’s first rule out when not to use the ABN.

An ABN CANNOT be used in a 9-1-1/emergency situation. The rules that govern the presentation of this form is prohibited in an emergency setting.

The theory behind this prohibition is that the patient cannot properly comprehend making an informed choice of ambulance providers, nor is there probably an option to use another ambulance company in an “emergency” scenario. Therefore, presenting this form is not allowed in the emergency setting.

ABN use is narrow and limited…

Use of the ABN is very narrow and limited.

Specifically, the ABN is mandatory when the patient could use services at his/her origin facility but is being transported to a second facility anyway as Medicare will not pay for this transport and the patient will be billed for the full cost of the trip.

This basically narrows the use of the ABN to an inter-facility scenario where, for some reason, either the patient or the facility is insisting that the patient be transported from Facility A to Facility B but where the services the patient requires were available at Facility A.

In Theory

The theory behind the ABN is to allow the patient (or a patient representative) to make an informed decision to use your EMS agency, another EMS agency or refuse the transport. Because of this, there are two key parts of executing the form which we will discuss in detail in Part 2 of this blog series…

  • Presenting a good-faith estimate of the dollar amount the patient will be billed for the service.
  • Presentation of the form and executing it prior to the patient’s being loaded into the ambulance.

Once presented, the form should be explained and then read over carefully by the patient and/or patient representative as he/she will need to make a crucial decision about continuing with the pending transport and will indicate his/her decision using the ABN.

Optional Use

The ABN may also be used by your EMS agency, optionally, to alert the patient to possible personal financial responsibility outside of the mandated use.

The form may be used as a courtesy to inform the patient when there may be a personal liability for…

  • Loaded mileage for a transport beyond the closest appropriate facility
  • Ambulance transportation services provided to a patient who does not meet medical necessity criteria
  • Ambulance transportation to a doctor’s office or other non-covered destination
  • Convenience transports such as a transport to be closer to family or for personal physician treatment preference
  • Use of higher level of service (ALS) when a lower level of service (BLS) would suffice
  • Non-Transport Paramedic Intercept services
  • Transportation by wheelchair, stretcher van or car services

Even though your EMS agency is permitted to bill any of the above without a signed ABN, your agency may choose to provide advance notice to your patients using this form so there is no “sticker shock” following the patient’s receiving your bill for services.

The Ambulance Billing Services blog is brought to you as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS third-party billing contractor serving Fire/EMS agencies across the United States. To learn more about who we are and what we do, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.